Two pediatric radiologists are having a heated agreement in the online pages of the Journal of the American College of Radiology. Both feel strongly that Image Gently, the pediatric radiation-reduction campaign, should be terminated. But they arrive at that point via divergent paths—and by ascribing quite different connotations to the term “terminated.”

That’s not surprising, given that one of the interlocutors is the current chair of the Alliance for Radiation Safety in Pediatric Imaging, aka the Image Gently Alliance.

The discussion got underway in June, when Mervyn Cohen, MD, of Indiana University weighed in. His unambiguous conclusion succinctly conveys the thrust of his argument:

“Terminate ALARA (as low as reasonably achievable) and Image Gently as they now exist. Stop the endless publications on the subject of CT and cancer. What bad outcomes do you fear from stopping ALARA and Image Gently? Patient cancer risk from CT is nonexistent or minimal, equivalent to normal everyday risks of living, and yes, there are huge negatives from ALARA and Image Gently. Radiologists have many more important issues and challenges to deal with than CT and cancer.”

On Sept. 1, JACR published a counterpoint essay by Donald Frush, MD, of Duke and the Image Gently Alliance.

“I applaud Dr. Cohen. His position is welcomed and should be heard and discussed,” Frush writes. “We must constantly evaluate what the Image Gently Alliance’s mission is, and to this end what we are doing well and what we might be doing poorly. This is healthy and necessary.”

At the same time, Frush notes in so many words, the road one follows to arrive at a conclusion can’t help but color the conclusion.  

“Journeys can … change the way you look at issues,” Frush writes. “We have evolved as an organization from one emphasizing radiation dose reduction as the primary platform to one focused on improving radiation use and the importance of continuing to emphasize the profound value of imaging. We also need to remind ourselves of study quality and the fundamentals of performance.”

Fleshing out the latter point, Frush cites a recent study comparing CT appendicitis exams at varying sites. The researchers found no significant differences in dose metrics between the reviewed patient populations—but 40 percent of the exams used techniques that investigators considered suboptimal, such as no use of intravenous contrast media.

Here Frush writes:

“We need to constantly assess and reevaluate our messages, our messaging and our audiences. We need to improve advocacy in the use of social media. We can do better here. It is difficult to keep content current. Given the limited resources of Image Gently as a volunteer organization, it is difficult to constantly battle the loud voices of ‘harm and alarm,’ which seem to be coveted with great promotional sympathy through the media. It is also challenging to maintain objectivity through independence, free from conflict of interest and the lure of fiscal sirens.”

Which brings Frush back to his nuanced agreement with Cohen that Image Gently should be terminated.

“When the Image Gently Alliance leadership transitioned from the visionary guidance of Marilyn Goske, MD, over the past two years, I said, during my first steering committee meeting as we were formalizing our strategic plan, that my mission was actually to make Image Gently unnecessary,” Frush writes. “It was provocative, perhaps a little disturbing, given the purpose-driven efforts to date. I remain optimistic that we will get there. But we are not there yet. This consensus and valued calling must continue.”